Medication - Mood Stabilisers

Medicines which are taken long term are often called mood stabilisers. These drugs are used both to treat mania as well as to prevent further episodes of mania and depression. They reduce the extreme changes of mood and activity that are responsible for the disturbances in sleep, appetite, thought processes, judgement and sexual activity that occur in manic depression. It is generally preferable to take these medications on a continuous rather than 'stop-start' basis.

They can also be supplemented with short-term medications should it be necessary. For example, anti-psychotics and/or benzodiazepines might be used if you notice the early signs of a manic relapse, feeling anxious, losing sleep or facing a stressful life event. Another option may be to increase the dosage of your long-term medication.

Common mood stabilisers include:

Lithium
Sodium Valporate
Olanzapine
Lamotrigine
Carbamazepine

Lithium

Lithium can take from a few days to several weeks before it is fully effective. Before taking this medication you should undergo a number of tests to check heart, kidney and thyroid function. Once you have started taking it you will need to have regular blood tests to monitor the amount of lithium in your bloodstream. At first, these tests should be done at least weekly, then, once serum levels have stabilized, every three months. Renal and thyroid function should be checked at least annually.

Lithium should never be stopped abruptly as this may cause a worsening of your illness; it should always be stopped gradually, reducing the dose over a period of 2-4 weeks. It is also important to keep to the same "brand" of lithium as different brands may give different blood levels (even though the dose is the same). Lithium is removed from the body by the kidneys. It reduces the ability of the kidney to conserve water, so urine output is increased. It is therefore important to drink a reasonable amount of water (usually within the range of 4-6 pints a day), but avoid dramatically increasing or decreasing your fluid intake.

As caffeine causes water loss it is also wise to limit the amount of tea, coffee and cola drinks in your diet. In addition, avoid too much or too little salt, or changing the amount of salt in your diet. If you have persistent diarrhoea, vomiting or dehydration from any other cause it is
important to consult your G.P. as there is a risk of lithium toxicity from too high a concentration of lithium in the blood.

Side Effects

The side effects of lithium can include nausea, diarrhoea, rashes, tremor, muscle twitching, weight gain, fluid retention, thyroid problems, acne, increased thirst and urine production, sedation or lethargy, blurred vision, cognitive problems and problems with co-ordination.

Dosages

Drug: Lithium carbonate, Lithium citrate, Priadel liquid
Commercial name: Priadel, Camcolit, Liskonum Lithonate, Litarex
Usual daily dose/mg: 600-1600mg
N.B. Dosage must be individualised according to serum level and clinical response.

Sodium Valproate

This is an anticonvulsant drug that is also used in the treatment of bipolar disorder. Valproate appears to prevent manic and depressive relapse.

It may be used in conjunction with lithium. Care should be taken when switching between brands as they are not all the same. Just like lithium you should not normally be switched between different types of valproate as the different plasma levels may lead to a worsening of your symptoms.

Side Effects

A very rare but serious side effect is liver toxicity and failure. Tests should be conducted before treatment is initiated, and liver function tests should be repeated in the first six months Valproate semisodium is the licensed and evidence-based valproate preparation for bipolar disorder. Common side effects include; indigestion, nausea, vomiting, drowsiness, confusion, temporary hair loss, tremor, rash, lethargy and weight gain.

Valproate may interact with anticoagulant medication and Tagamet/Cimetidine (antiulcer drugs).

Dosages

Drug: Valproate semisodium
Commercial name: Depakote
Usual daily dose/mg: 750-2000mg

Drug: Sodium valproate
Commercial name: Epilim, Epilim Chrono (CR)
Usual daily dose/mg: 1000-2000mg

Drug: Valproic acid
Commercial name: Convulex
Usual daily dose/mg: 750-1600mg

Olanzapine

Olanzapine is an antipsychotic antimanic and mood stabilising agent. It can be used to treat both the mood symptoms and psychotic symptoms in mania. Olanzapine is also licensed to prevent recurrence of bipolar disorder (long term treatment) people whose manic episode has responded to olanzapine. In these instances, olanzapine can be used as a foundation therapy for the treatment of the disorder.

Olanzapine can be used as either a monotherapy or in combination with other mood stabilisers. Olanzapine is not associated with serious liver problems. Side effects can include; drowsiness, weight gain, low blood pressure, dry mouth, constipation, swelling of ankles, altered liver function and skin sensitivity to sunlight. In very rare cases hyperglycaemia (high glucose levels) has been reported.

Quetiapine is a newer atypical antipsychotic, which can be used to treat both mood symptoms and psychotic symptoms. Quetiapine has not been associated with serious liver problems and regular blood tests are not required. As with Olanzapine, Quetiapine does not tend to produce the movement disorder side effects common with the older antipsychotics.

Side Effects

Side effects can include constipation; dizziness, lightheadedness, or fainting, especially when getting up from a lying or sitting position; drowsiness; dry mouth; indigestion; increased weight (although there is some evidence of weight gain, this may not be as high as with some other medications).

Lamotrigine

Again, this medication was originally developed to treat epilepsy, and may be considered where depression is the major burden of the illness.

It has been shown to prevent depressive relapse, but is not generally as effective in preventing manic relapse. As with Valporate Semisodium and Olanzapine, there is anacdotal evidence that it is being used effectively where people experience rapid cycling or mixed affective disorder. Rarely, some people show features of both mania and depression at the same time. They are hyperactive while experiencing depressive mood. Such people are said to have a mixed affective disorder. More research in this area would be helpful.

Side Effects

Side effects can include; drowsiness, dizziness, 'flu-like' symptoms, headache, swelling in the legs, face, lips or tongue, blurred vision. Urgent medical advice should be obtained if a rash occurs.

Carbamazepine

Carbamazepine was originally developed to treat epilepsy. It is less widely used than lithium and is generally less effective than lithium. Carbamazepine is used both to treat and prevent episodes of manic depression. It is especially useful for those people who do not respond
to or cannot take lithium. Regular blood tests (usually every 6 months) are needed to check the concentration in the blood.

Side Effects

Side effects may include gastrointestinal problems, dizziness, drowsiness, double vision, rashes, headache, constipation, confusion, swelling of the ankles and blood disorders. Carbamazepine may affect the effectiveness of the oral contraceptive pill. It may also interact with some antibiotics, blood pressure drugs and lithium.

Dosages

Drug: Carbamazepine
Commercial name: Tegretol, Tegretol Retard
Usual daily dose/mg: 400-1600mg

Drug: Oxcarbazepine
Commercial name: Trileptal
Usual daily dose/mg:1200-2400mg

N.B. Oxcarbazepine is similar to carbamazepine. It is a newer drug also licensed to treat epilepsy and appears to have fewer side effects than carbamazepine.

Get involved in a randomised controlled trial

We still lack the research-evidence needed to provide detailed guidance on the selection of long-term medications. A study known as BALANCE is addressing some of these questions. If you would like to be part of the trial and are over 18, have experienced a manic episode and are willing to take lithium, valproate semisodium or both, you can contact the BALANCE team on 01865 223731 or visit the BALANCE web site.

Introduction

Next (antipsychotics)